We are now more or less three years into North Carolina’s waiver evolution.  We must ask how our MCOs are doing with regard to serving citizens with the quality that reflects genuine respect for their well-being.  All too often, the discussion turns to service providers, yet the real question should effectively disclose the organizational culture of our public Managed Care Organizations.
With public dollars, Medicaid requires (and shall I say, so do many taxpaying citizens?) that they develop systems that ensure that people get the most appropriate services according to their need and to ensure that people experience improving health (and indeed, recovery in the case of most being served) with decreasing crises in their lives.   This effort goes way beyond developing new utilization management tools and tighter billing systems.  In fact, even if one were to look at an MCO as a corporate business model alone (and too many in our system do), it would not be effective nor certainly sustainable because the value of the customer’s experience is not part of the equation.
Value means that the dollar (the public dollar) is purchasing significant benefit for people needing the system.  Value should become our focus when considering the quality of our systems or our services.  Value should be the bottom line at the Department of Health and Human Services and the Governor’s office.  It should be the plain language used by legislators, especially those tasked with oversight of system funding and progress.
Value has not been the driver of the corporate or board cultures in most of our managed care organizations.  Growth has been.  Numbers and dollars.  And this is hurting us.  I so much wish that legislators and DHHS staff understood the very truth of this matter.
There isn’t space to explore examples from several MCOs (governance and leadership levels) that typify our concern about the lack of interest in the experience of the intended beneficiary and the outcomes of how he is served. But there are several very concerning circumstances!
Finally, here is another indicator of a troubling disregard for quality:  On June 5, Benchmarks, a training and development provider to the mental health system, had scheduled a very important presentation.  Called Building Resilience and Accountability:  Improving Individual, Family and Community Health Outcomes, I’d felt this was so well timed for North Carolina.  It is presented by a very knowledgeable and caring speaker in the field from out of state whom I have known for some time.  I had hopes that there would be many MCO staff hearing his message as well as Division staff and providers.  We need this discussion and we need it now!  Yet because of too little interest by constituents, Benchmark, has had to cancel the event.

So what does all this mean?  We have inadequate leadership in MCOs where communities will suffer as a result.  We have one organization letting go of one of the best leaders in our state because of a difference in values.  And we have too little interest by MCOs in evaluating their true values, organizational culture, and the outcomes necessary to ensure that they are offering a high-value system.
It all means it is a very sad day for North Carolinians who must depend on these MCOs.  And because many of these issues have been known to DHHS and some legislators, it may mean that no one with authority really cares.  Please, we deserve leaders with the right values shaping productive and humane cultures of management and service provision. We need all who can to step up to make a difference!


One other person’s word on this issue:  The following sentence was written to me by a very caring clinician in our system:

“Now that all of NC is covered by the Waiver, I am STILL waiting for outcome data.  Lots of eggs got cracked making this omelette and I’m still waiting to see whether it was worth it (financially, quality of services, client level of satisfaction with care, reduced hospitalizations, reduced wait times for care, etc.).”



  1. Corruption takes many forms in a government but the worst is to ignore what the taxpayer dollar is intending to buy and that is quality. Especially, when this applies to persons w/disabilities who depend on a government to purchase mental health care. To manage public dollars, one should want for others what they would want for themselves. That is the difference in having separate systems of care.

    • Thanks for your comment! Question: When you state “separate systems of care”, are you suggesting that if the care were integrated into one health care system, you feel the dollars would be more likely to purchase quality outcomes? I think that is what you are saying, and I probably agree, but I want to be sure this is what you have meant. Please clarify if you want to add anything. THANKS!

  2. Thanks for this timely and imporant commentary, Laurie C. There are a couple of things that require immediate attention to keep services available and effective: more oversight from citizens appointed to LME/MCO Boards of Directors and less emphasis on cost cutting and more emphasis, as you said, on the value created by the services.

    • I agree, Martha, except that I have grave concerns about the boards of some of our MCOs. They are fat with business thinkers and lean on quality thinkers. And unfortunately, in our community, if the minority of board members upholds quality and wishes to ensure rights, they are dismissed as “advocates” and not taken seriously. So they remain a vocal but ignored minority. And I think we should be concerned about what the thinking was on another board that recently dismissed its CEO because they wanted to go in another direction and focus more on expansion! These foretell a disappointing future.

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